Slaughter house 9-to-5

Re-read the below recently-- pains a fairly grim picture, but from the folks who have been here, things have been worse. So progress is happening. A favorite quote from Robert E Lee...

"My experience of Men has never disposed me to think worse of them, nor indisposed me to serve them; nor, in spite of failures which I lament, of errors I only now see and acknowledge, or of the present aspect of affairs, do I despair of the future. The truth is this: The march of Providence is so slow and our desires so impatient; the work of progress is so immense and our means of aiding it so feeble; the life of humanity is so long, that of the individual so brief, that often we see only the ebb of the advancing wave and are thus discouraged. It is history that teaches us to hope."



It's pretty impressive here. I'd say the “pathology” is “interesting,” but most if it doesn't live long enough to become so. It's a pretty standard occurrence to be called out to the drive-up receiving area by the triage nurse to pronounce a patient dead in the car. That way, the family isn't charged for the ER visit. Often a relatively young person will arrive in extremis, clearly a few days into the process, and all I can really do is watch them die. Sometimes not even that, depending on how busy things are. Usually they were recently seen (hopefully at another clinic/institution!) and sometimes have been taking some mystery pills for unknown reasons. So the family asks me at least for answers, if not hope. Why? What? Who's next? I don't know what to say. We have little ability to check basic chemistries, beyond a BUN (2 day turnaround), no microbiology, no functioning autopsy service. DOA, 2/2 BIA (dead on arrival secondary to born in Africa...?).
Often they appear gaunt, occasionally minimal responsive to noxious stimuli. More often than not I write for an HIV test (HIV, malaria smear, hemoglobin sometimes come back the same day...), whether or not I think they will last for the results (or the sampling). To a person, the family complains of them “Not eating.” A week is average.
So I write the standard orders for first dose quinine, ceftriaxone (or amp/gent, or benzylPCN or ampicillin, depending on review of systems and ability of the family to pay, as well as D50, fluids, paracetamol (please stop giving malaria patients NSAIDs IM! Platelets, platelets platelets...). Maybe I'll catch a septic patient right when it could matter. Maybe I'll put my hand on a belly and get the patient to OB or surgery. Maybe the social worker will approve emergency surgery so it can happen now, and not after sitting on the medicine ward for two days, filling with blood or pus. Maybe the kiddo will perk up, complete a quinine course po and go home. Maybe.
But the worst days are when I'm wrong. The baby looked ectopic to me on sono; the spleen suspicious for abscess. I thought that TB patient was stable to go back to chest clinic, where they had his meds and chest x rays and records. But I was wrong. Or I still don't know. Patient sat on the wards, and died a few days later-- no feedback, no closure. DAA 2/2 BIA (died after admission, secondary to born in Africa).
I guess I sound melodramatic, but perhaps blogs are supposed to be evocative? The truth is, I start out in morning report, trying to make something useful out of them. I'm then in the medical ER 9-5, w/ a PA on the surgical side during that time (I wander over now and then and try to suture or reduce something). The interns/residents here haven't really taken to signing in or out the ER patients. I track them down and tell them if there's someone critical in the ED. Any spare moment I have I try to teach something to the PA students. Anyone who will listen, really. Take my book, take my pen, look at my video on splinting from the NEJM! I've said before to a med student here, if there's anyone taking care of anyone in Liberia in 40 years, it's going to be from the group of people who are training now (or people they have trained). They are the reason I came to Liberia. Maybe if I inspire someone to try harder, learn more, be upset when people die, then maybe I'll have done something with my time here. And that may be the real hope for those of us BIA. For any of us, really.